First Responder for In-Hospital Resuscitation: 5-Year Experience with an Automated External Defibrillator-Based Program

doi:10.1016/j.jemermed.2012.11.036

The Journal of Emergency Medicine

Volume 44, Issue 6, June 2013, Pages 1077-1082

https://doi.org/10.1016/j.jemermed.2012.11.036 Get rights and content

Abstract

Background

The survival of in-hospital cardiac arrest (8–25%) has not changed substantially in the past. Until now, most hospitals in Germany had no standardized protocols available for a course of action in case of emergency, and there are no continuous registry data for in-hospital cardiac arrest and survival.

Objective

Our aim was to improve survival and receive outcomes data, so we implemented a structured hospital-wide automated first-responder system in the hospital. Here our 5-year experience with 443 emergency calls is outlined.

Methods

Throughout the hospital, 15 automated external defibrillator (AED) “access spots,” which can be easily reached within 30 s, were identified. AEDs were then installed at these locations (Lifepak 500 and Lifepak 1000, Medtronic equipped with a Biolog 3000i portable ECG monitor). At the same time, a training program was initiated in which the employees of the hospital participated once a year. Participants learned how to apply and activate an AED in case of cardiac arrest even before the designated Cardiac Arrest Team arrived at the scene.

Results

A witnessed cardiac arrest event was confirmed in 126 cases. In 56 of the 126 cases, the primary arrest rhythm was either ventricular tachycardia or ventricular fibrillation and the AED delivered a shock. In this group, spontaneous circulation was reached in 44 cases (79%) and 23 patients (41%) were discharged. In 44% (24 from 55 patients) of the cases, a shock was recommended by AED and delivered by the first responders before the rescue team arrived.

Conclusions

The first-responder AED program successfully gave training lessons to the hospital staff. The training included how to initiate the cardiac arrest call, how to use the AED, and how to start immediate resuscitation. As a result, a higher survival rate after in-hospital cardiac arrest can be accomplished.

Introduction

The International Liaison Committee on Resuscitation has given a class I recommendation for immediate defibrillation as the treatment of choice for ventricular fibrillation (VF) of short duration that occurs in witnessed sudden cardiac arrest. The goal for early defibrillation in hospital and ambulatory clinics is to deliver a shock within 3 min of the victim’s collapse. With the introduction of automated external defibrillators (AEDs), the concept of a first-responder AED program has been increasingly advocated for in-hospital settings by numerous authors to increase the survival rate for in-hospital cardiac arrest (8–25%) reported previously in the literature 1, 2, 3, 4, 5, 6. Until now, most hospitals in Germany had no standardized protocols available for a course of action in case of emergency, and there are no continuous registry data for in-hospital cardiac arrest and survival. Therefore, it is hypothesized that the outcomes data after in-hospital cardiac arrest do not significantly differ from documented sources in the literature.

To establish a structured program for in-hospital resuscitation, a hospital-wide step-by-step protocol has been developed. This protocol is based on a first-responder system. Having a first-responder system in place implies that any hospital employee, regardless of the professional education, should be able to act as a first responder in an emergency situation. Whether or not there might be differences in the outcomes due to different training levels of first responders is not yet known, and is currently subject to investigation. In this system, the local emergency response system can be activated in any area and the skill and equipment, including an AED, are available to provide rapid defibrillation. This concept has technical and organizational requirements, as well as standardized documentation and program evaluations 3, 7. In the present study, our 5-year experience is outlined.

Section snippets

Methods

St. Josef Hospital is a 683-bed hospital and part of the Bochum University Hospitals. The hospital provides care for >24,000 inpatients per year in its 27 wards. Before establishing this new program, a Cardiac Arrest Team was alerted and arrived at the scene in case of an event via a group-call paging system that was initiated by the hospital switchboard operator upon receipt of a cardiac arrest call. The Cardiac Arrest Team consisted of three medical staff members (one qualified intensive care

Results

During the data collection, which took place from April 1, 2004 to March 31, 2009, there were 443 emergency calls, which came predominantly from nurses in the wards with cases of impaired consciousness that could be a cardiac arrest. The Cardiac Arrest Team was requested for help and calls were recorded via the switchboard operator. In 98% of the cases, the elapsing time until first response started was <3 min after making the cardiac arrest call. A witnessed cardiac arrest event was confirmed

Discussion

This study describes a 5-year experience of a widespread implementation of AED-supported early defibrillation in a medium-sized university hospital combined with a newly implemented training program. The purpose was to teach the concept of first-responder AED defibrillation even before the designated Cardiac Arrest Team arrived at the scene in case of cardiac arrest 9, 10, 11.

When in-hospital cardiac arrests occur in a hospital without a standard resuscitation protocol, the literature reports a

Conclusions

Results of the reported first-responder AED program showed that training lessons were given successfully to the first responders, and they are able to initiate the cardiac arrest call, use the AED, and begin with immediate resuscitation. In so doing, a higher survival rate after in-hospital cardiac arrest can be accomplished, especially for patients with VT or VF.

Article Summary

1. Why is this topic important?

Until now, most hospitals in Germany had no standardized protocols available for a course of action in case of cardiac arrest, and

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Cited by (10)

Barriers and facilitators for successful AED usage during in-situ simulated in-hospital cardiac arrest
2022, Resuscitation Plus
Citation Excerpt :
Early defibrillation for shockable rhythm increases survival.6–9 Automated external defibrillators (AEDs) may contribute to earlier defibrillation while awaiting the arrival of the cardiac arrest team and a manual defibrillator.10,11 In Scandinavian countries, 90% of cardiac arrests occur outside of the intensive care unit where AEDs may be the only option for early defibrillation.12,13
Early defibrillation within minutes increases survival after in-hospital cardiac arrest (IHCA). However, early defibrillation is often not achieved even though automated external defibrillators (AEDs) are available. We aimed to investigate how AEDs were used and the barriers and facilitators for successful use.
We conducted unannounced, full-scale in-situ simulations of IHCAs in hospital wards with an AED. A debriefing followed the simulations. The simulations and debriefings were video recorded, and the debriefings were transcribed for subsequent qualitative analysis about the AED use.
We conducted 36 unannounced in-situ simulations, and an AED was used in 98% of simulations. It was decided to collect an AED after a median of 62 (31; 123) seconds, the AED arrived after 99 (82; 146) seconds, were attached after 188 (150; 260) seconds, and the first shock were delivered after 221 (181; 301) seconds from time of cardiac arrest diagnosis. We identified three main domains related to barriers and facilitators of AED use: teamwork, knowledge, and transfer. Frequent reasons for successful use of an AED were recent resuscitation course, previous experience, and leadership. Reasons for unsuccessful use were doubt about responsibility, lack of knowledge, and lack of contextualized training.
During unannounced simulated IHCAs, time to defibrillation was often > 3 minutes. Most of the delay occurred after the AED was collected. Non-technical skills and contextualized training were among the main perceived barriers to AED usage. Facilitators for successful use included recent training, previous experience, and successful leadership.
An outcome study of adult in-hospital cardiac arrests in non-monitored areas with resuscitation attempted using AED
2020, American Journal of Emergency Medicine
Citation Excerpt :
Rather, some reports described that the use of AED impaired IHCA outcomes [17-20]. Despite the poor supportive evidence, AEDs have been widely used in hospitals, with expectations for an improvement in resuscitation outcome in areas where emergency medical teams and manual defibrillators are not immediately available [14-16]. If on-site nurses and other medical staff have been sufficiently trained for basic life support using AED, an improvement of outcome would be especially expected in patients with shockable rhythms [12-16].
To investigate the outcomes of patients with in-hospital cardiac arrest (IHCA) who underwent cardiopulmonary resuscitation (CPR) using an automated external defibrillator (AED) in non-monitored areas. Additionally, to detect correlated factors associated with rate of return of spontaneous circulation (ROSC) and survival rate, among collected data.
This study included 109 patients. After investigating patient characteristics and resuscitation-related factors, the correlated factors associated with ROSC rates and survival rate were analyzed using univariate and multivariate analyses.
The rate of survival to hospital discharge was 21.1%. CPR with AED performed since 2013 was associated with a higher ROSC rate (adjusted odds ratio [AOR] 3.24, 95% confidence interval [CI]: 1.21 to 9.52, p < 0.05), but not with the survival rate after ROSC. Tracheal intubation was significantly associated with a higher ROSC rate (AOR 3.62, 95% CI: 1.27 to 11.7, p < 0.05) and a lower survival rate after ROSC (hazard ratio 6.6, 95% CI: 1.2 to 43.3, p < 0.05). Dysrhythmia as the cause of cardiac arrest and intensive care unit (ICU) admission after ROSC were associated with higher survival rates (hazard ratio 0.056, 95% CI: 0.004 to 0.759, p < 0.05, and hazard ratio 0.072, 95% CI: 0.017 to 0.264, p < 0.0001, respectively).
The factors associated with ROSC rate and those associated with the survival rate after ROSC were different. Although initial shockable rhythms on AED were not associated with the survival rate, dysrhythmia as the etiology of cardiac arrest, and ICU admission were significantly associated with higher survival rates after ROSC.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 2. Adult basic life support and automated external defibrillation.
2015, Resuscitation
Citation Excerpt :
Two older, observational studies of adults with in-hospital cardiac arrest from shockable rhythms showed higher survival-to-hospital discharge rates when defibrillation was provided through an AED programme than with manual defibrillation alone.223,224 A more recent observational study showed that an AED could be used successfully before the arrival of the hospital resuscitation team.225 Three observational studies showed no improvements in survival to hospital discharge for in-hospital adult cardiac arrest when using an AED compared with manual defibrillation.226–228
Effects of two retraining strategies on nursing students' acquisition and retention of BLS/AED skills: A cluster randomised trial
2015, Resuscitation
Citation Excerpt :
Nurses are usually either direct witnesses or first responders to in-hospital cardiac arrest incidents.6,13,14 Therefore, all nurses, regardless of their expertise, are expected to be able to rapidly recognise a cardiac arrest and quickly activate the emergency system in place, to immediately initiate effective cardiopulmonary resuscitation (CPR), and to safely use an AED.13–17 The training of these BLS/AED skills is part of most undergraduate nursing programmes.
To determine and compare the effects of two different retraining strategies on nursing students’ acquisition and retention of BLS/AED skills.
Nursing students (N = 177) from two European universities were randomly assigned to either an instructor-directed (IDG) or a student-directed (SDG) 4-h retraining session in BLS/AED. A multiple-choice questionnaire, the Cardiff Test, Laerdal SkillReporter^® software and a self-efficacy scale were used to assess students’ overall competency (knowledge, psychomotor skills and self-efficacy) in BLS/AED at pre-test, post-test and 3-month retention-test. GEE, chi-squared and McNemar tests were performed to examine statistical differences amongst groups across time.
There was a significant increase in the proportion of students who achieved competency for all variables measuring knowledge, psychomotor skills and self-efficacy between pre-test and post-test in both groups (all p-values < 0.05). However, at post-test, significantly more students in the SDG achieved overall BLS/AED competency when compared to IDG. In terms of retention at 3 months, success rates of students within the IDG deteriorated significantly for all variables except ≥70% of chest compressions with correct hand position (p-value = 0.12). Conversely, the proportion of students who achieved competency within the SDG only decreased significantly in ‘mean no flow-time≤5s’ (p-value = 0.02). Furthermore, differences between groups’ success rates at retention-test also proved to be significantly different for all variables measured (all p-values < 0.05).
This study demonstrated that using a student-directed strategy to retrain BLS/AED skills has resulted in a higher proportion of nursing students achieving and retaining competency in BLS/AED at three months when compared to an instructor-directed strategy.
Use of automated external defibrillators for in-hospital cardiac arrest: Any time, any place?
2019, Medizinische Klinik - Intensivmedizin und Notfallmedizin
Association between prompt defibrillation and epinephrine treatment with long-term survival after in-hospital cardiac arrest
2018, Circulation

View all citing articles on Scopus

: Drs. Kloppe, Jeromin, Ernst, and Hanefeld contributed equally to this work.

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Original ContributionsFirst Responder for In-Hospital Resuscitation: 5-Year Experience with an Automated External Defibrillator-Based Program

Abstract

Background

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Article Summary

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Organisation of an hospital-wide first responder AED outside critical care areas

Resuscitation

Voraussetzungen zur Anwendung von automatischen externen Defibrillatoren in deutschen Krankenhäusern

Anaesthesist

Aktuelle Leitlinien des European Resuscitation Council

Notfall Rettungsmedizin

Anforderung an ein innerklinisches Notfall-Management-System

Deutsch Med W

Original Contributions
First Responder for In-Hospital Resuscitation: 5-Year Experience with an Automated External Defibrillator-Based Program